Healthcare Provider Details

I. General information

NPI: 1154442671
Provider Name (Legal Business Name): BARBARA ANN DAVIS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

265 W 104TH ST
CHICAGO IL
60628-2509
US

V. Phone/Fax

Practice location:
  • Phone: 773-869-7488
  • Fax: 773-869-3578
Mailing address:
  • Phone: 773-785-2365
  • Fax: 773-785-2365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number85001108
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-001108
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: